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Lung & thorax
      SAH & RNSH 2011
Critical Care Ultrasound Course
          Thanks to:
       Dr Paul Atkinson
       Dr Bishr Faheem
    Dr Daniel Lichtenstein
Scanning the lung
•   Why scan the lung?
•   Probe & scanner settings
•   Technique
•   Landmarks
•   US findings
•   Terminology: the lung profiles
•   Matching the findings to the disease
•   Sticking needles & tubes in the lung
                                           2
Why scan the lung?
•       Diagnosis
    •     Air in pleura: PTX
    •     Fluid in pleura: blood, pus
    •     Fluid in lung tissue: APO/ pneumonia /
          ARDS
    •     Consolidated lung tissue: pneumonia /
          contusion / infarct (PE) / cancer
•       Procedures

                                              3
Why bother?
•   Lung US is more accurate than CXR for:
        • PTX (>95% versus 50%)
        • Pleural fluid (20ml versus 200ml)
        • APO sens 97%, spec 94%, acc 95%
        • PE?? Sens 74% … 81% if add DVT
•   It’s also
        • Faster (2 min versus 19 min)
        • Safer
        • Repeatable                       4
The Technique




                5
Patient position
!   No need to sit patient up (eg trauma)
!   In fact, accuracy for PTX is improved if
    lying flat… just harder to get round the
    back for pleural fluid
!   Air rises
!   Fluid sinks



                                      6
Probe
!   Ideally the curved probe
!   Linear array no anatomical info
!   Phased array poor image quality




                                      7
Preset
!   Abdo / FAST
!   Not the commercial ‘lung’ settings
!   Turn off filters
    !   Multibeam / compounding
    !   Tissue harmonics
!   Why? You are looking for artefacts



                                     8
Depth
!   Close up consolidation? = 5cm
!   Just sliding / A / B lines? = 10cm
!   Base of lung / diaphragm? = 15cm
!   Making sure rockets are rockets? =
    15cm




                                     9
Probe position
!   Sagittal
!   Right angles to the ribs
!   Makes sure that the landmarks (rib
    shadows) stay in view




                                     10
Find those ribs


  ‘RIB’
          ‘RIB’




                  11
Look between the ribs


          RIB
                         RIB




  PLEURAL LINE (WHERE THE ACTION IS)


                                       12
So:
!   Curved probe
!   FAST / abdo preset
!   10-15cm depth
!   Turn off fancy filters
!   Sagittal / long axis of patient




                                      13
Where will I scan?



 Depends on clinical context




                               14
The basic principle
!   Air rises " scan highest point of the
    chest
!   Fluid sinks " scan lowest point
!   Some diseases are patchy (eg
    pneumonia, ARDS) " scan as much of
    the lung as possible (at least look at
    each lobe)


                                     15
Where will I scan?
!   Cardiac arrest: highest point on each side

!   Shock: 2 anterior (BLUE) points on each side

!   Breathless: 3 points on each side
    !   Add 1 posterior (PLAPS) point


!   Thorough look: as much of each lung as
    possible (improves accuracy)
                                           16
BLUE points & PLAPS points




                      17
BLUE points & PLAPS points
!   What the %$#% ???
!   Daniel Lichtenstein’s BLUE protocol
!   BLUE is not an acronym
!   PLAPS is, though




                                     18
BLUE points & PLAPS points
!   Upper BLUE point = upper lobe
!   Lower BLUE point = middle lobe /
    lingula
!   PLAPS point = lower lobe




                                       19
Lichtenstein’s BLUE points




                       20
Lichtenstein’s BLUE points in theory




                                21
Lichtenstein’s BLUE points in theory




                                21
Lichtenstein’s BLUE points in practice




                                 22
Lichtenstein’s BLUE points in practice




                                 22
Lichtenstein’s PLAPS point




                       23
PLAPS point
!   ‘Postero- Lateral Alveolar / Pleural
    Syndrome’
!   What the %$#% ???
!   Posterolateral = round the back
!   Alveolar syndrome = consolidation
!   Pleural syndrome = pleural fluid



                                      24
PLAPS point
!   The PLAPS point is the lowest point of
    the lung
!   The Morison's Pouch of the
    thorax’ (thanks to Dr Chris Wong)
!   So this is where you find pleural fluid
!   If there’s no fluid here, there’s no fluid
    anywhere in the thorax!


                                      25
How to find the PLAPS point
!   It’s the posterior continuation of the
    lower BLUE point (as far around as you
    can get the probe)




                                     26
How to find the PLAPS point




                      27
How to find the PLAPS point




                      27
Tip: watch out for the abdomen!

!   If you scan the liver / spleen & think you’re still
    above the diaphragm, it will resemble consolidation
!   ESP if you are using linear probe




                                                28
Tip: Get round as far back as you can!




     wrong                   right


                                     29
Tip: Get round as far back as you can!




     wrong                   right


                                     29
Tip: Get round as far back as you can!




     wrong                   right


                                     29
Normal lung




              30
NB: ‘normal lung’
!   Pleural line looks like a ‘curtain’ sliding
    back & forth
!   Sparkle = scatter from air in lung
!   You don’t really seeing normal lung at
    all
!   If it looks like liver:
    ! mirror
    ! hepatization


                                         31
What am I looking for?




                    32
What am I looking for?

! Pleural fluid
! Pleural sliding

! A lines: reverb artefact from pleural line

! B lines: hyperechoic reverberation effect
  from air/water interface
! C: consolidation




                                        33
Pleural fluid




               34
Pleural fluid

! Site: dependent regions
! Appearance:
    ! black = anechoic (fresh blood, transudate/
      exudate)
    ! echogenic / stuff = blood, exudate

! Amount: as little as 20ml
! Sensitivity >97%, specificity 99-100%
  (Sisley et al, J Trauma 1998)

                                             35
Pleural fluid




               36
Pleural fluid




               36
Pleural fluid




               37
Pleural fluid: caveats

! Pleural vs pericardial fluid (pericardial =
  delimited by descending aorta)
! Peritoneal fluid (where’s the diaphragm?)

! Small traces of fluid: easy to miss




                                       38
Pleural or pericardial fluid?




                        39
Duh! Just look all over the thorax
A, B & Z lines




                 41
A, B & Z lines
!   A lines = horizontal & static =
    reverberation artefact from pleura
!   B lines = vertical & move with resps
    (prev ‘comet tails’) = thick vertical lines
    which reach to edge of screen &
    obliterate A lines
!   Z lines = vertical, fade quickly, don’t
    move with resps

                                        42
A lines




          43
A lines




          44
A lines
Horizontal artefacts
 Only air is present
Present in dry lungs
   Present in PTX




                       45
B-line




     B line




              46
B lines
           Vertical artefacts
  Air/fluid mix in interlobular septa
      Equivalent of Kerley B lines
            Not seen in PTX
Even 1 B line rules out PTX at that site




                                   47
B lines
               Vertical
                Bright
          Obliterate A lines
             Don’t fade!
Reach all the way to the edge of the
                screen!
    1 or 2 per lung field is OK
       3 or more = ‘rockets’
                                 48
Z-lines(Note: A line maintained)




                                   49
Z lines

!   ill defined
!   DON’T move with respiration
!   DON’T erase the A lines




                                  50
Lung rockets

‘When several B lines are visible in
  a single scan, the pattern
  evokes a rocket at lift-off, and
  we have adopted the term ‘lung
  rockets’’ (Lichtenstein p106)

                                       51
Lung rockets

3 or more B lines per lung field =
             ‘rockets’




                                    52
Not ‘comets’

International consensus dropped
  the term (terminology is
  confusing enough already)



                              53
Rockets




          54
Rockets




          54
Top Tip

Up to 1/3 normal patients have rockets in
             dependent regions
 So if you see rockets in PLAPS points, it
               doesn’t matter!



                                        55
Lung rockets = wet lungs
! Just in the bases = normal
! In all windows = cardiogenic oedema

! Patchy, with spared areas = non
  cardiogenic oedema / widespread
  pneumonia
! Localised = pneumonia / chronic
  interstitial diseases eg fibrosis




                                    56
Test

Remember: 1 or 2 B lines are OK.
 Lung is still dry at that point!




                                57
A, B or Z lines? Dry or wet?




                               58
A, B or Z lines? Dry or wet?




                               59
A, B or Z lines? Dry or wet?




                               60
A, B or Z lines? Dry or wet?




                               61
Applications of lung rockets

!   Diagnosis
    !   Is it his CCF or COPD playing up today?
!   Fluid status
    !   is this guy with a crap LV overloaded today?
!   Guiding fluid resuscitation
    ! Fill him up until the rockets appear
    ! Dialyse him until the rockets disappear




                                                  62
Validation
!   Volpicelli et al, Am J Emerg Med 2006 (24):
    689-696
     ! N=300 (75 had AIS)

     ! Combined gold standard incl 1 month
       follow up

    ! 

   
 
 
 
 
 sens
 
      spec
    ! Rockets
 
    85.7%
     97.7%

                                          63
Just remember
    !  Not all vertical lines are B lines
       ! Z lines = puny

       ! pseudo-rockets with subcut emphysema (don’t
         move with respiration, & can’t see normal rib
         shadow above them)
     ! Not all rockets = fluid

       ! widespread pneumonia

       ! widespread fibrosis

!   rockets can be normal in lowest intercostal space
!   Posterior lung rockets can be normal in supine
    patients
                                               64
Lung sliding




               65
Lung sliding

!   Visceral pleura glides on parietal pleura
!   Why is it important?
!   A lines + sliding = dry lung = A profile
!   A lines without sliding = PTX = A’ profile
!   Rockets + sliding = APO = B profile
!   Rockets without sliding = ARDS / pneumonia
    = B’ profile


                                        66
Lots of things can prevent
       lung sliding
! CAL
! Apices

! Failure to ventilate
    !   eg R main stem intubation (L lung doesn’t
        move)
    !   Eg pain (chest splinting)
! Pneumothorax
! Pneumonia & ARDS




                                              67
Lots of things can prevent
       lung sliding
! CAL
! Apices

! Failure to ventilate
    !   eg R main stem intubation (L lung doesn’t
        move)
    !   Eg pain (chest splinting)
! Pneumothorax
! Pneumonia & ARDS … ???




                                              68
How the hell do pneumonia /
 ARDS reduce lung sliding?




                       69
Here’s how:

 ARDS/ disseminated           APO:
      pneumonia:          Transudate
       Exudate           Lung sliding is
   Proteinaceous        preserved, smooth
       ‘sticky’            pleural line
Reduced / absent lung       B profile
   sliding, irregular
      pleural line
      B’ profile
Is sliding preserved?
Is sliding preserved?
Is sliding preserved?
Is sliding preserved?
Is sliding preserved?
So how do I diagnose PTX?




                       74
Diagnosis of PTX
1.   No lung sliding
2.   No B lines
3.   Ideally, a lung point




                             75
1. a o lung sliding
   N




                      76
Which side is the PTX?
Which side is the PTX?
Which side is the PTX?
Tip 1: compare sides




                       78
Tip 1: compare sides




                       78
Tip 1: compare sides




                       78
Tip 2: M-mode can help

!   Sliding = seashore sign
!   No sliding = stratosphere sign
!   But beware ‘false seashore’ with chest
    wall movement!




                                     79
Normal: seashore sign




                    80
PTX: stratosphere sign




                    81
Stratosphere sign
!   M-mode = motion mode
!   If something isn’t moving, it’s a
    straight line




                                        82
2. No B lines
•       i.e. the A’ profile (air is dry)
•       Even a single B line rules out PTX
•       Because B lines = air/fluid interface
•       Absent sliding + B line = LUNG
    •     EG not ventilating
    •     EG pneumonia




                                           83
3. The lung point sign
!   Specific to PTX
!   the site where normal lung gives way to PTX
!   on one side of the image sliding is present
!   on the other side it is absent.




                                         84
Lung point sign




                  85
What if there’s no lung point sign?



there might still be a massive PTX which has
  collapsed the entire lung. Go back to the
  clinical picture & decide whether you need
  to go ahead & decompress the chest.




                                        86
Can I trust lung US for PTX?
         If you are just starting out:
 ! If you want to find all PTX: get a CT

 ! Stable patient, Negative CXR, positive
   EFAST: get a CT … or ask a friend to scan
 ! Unstable patient, Negative CXR, positive
   EFAST: decompress the chest
 ! Rushing to OT/ chopper, neg CXR, pos
   EFAST: warn anaesthetist or insert ICC


                                      87
Test




       88
Sliding or not?




                  89
Sliding or not?




                  90
Sliding or not?




                  91
Sliding or not?




                  92
Consolidation
a.k.a. the C profile




                      93
Alveolar consolidation
! If you can see lung tissue, it ain’t normal!
! It ain’t aerated
    ! Collapse
    ! Consolidation

    ! Atelectasis

    ! Contusion

    ! Infarction (PE)




                                        94
Alveolar consolidation




                     95
Putting it all together




                      96
Terminology

•   A profile = A lines (or no lines), sliding preserved
•   A’ profile = A lines (or no lines), sliding absent
•   B profile = lung rockets in all windows, sliding
    preserved
•   B’ profile = lung rockets in all windows, sliding
    reduced / absent
•   A/B profile = patchy rockets alternate with normal
    areas
•   C profile = areas of consolidation
•   PLAPS positive = consolidation / effusion at bases
•   PLAPS negative = anything else at bases (A lines /
    B lines / rockets)
A word of advice about the A profile

•   All A lines = A profile
•   No lines seen? Still = A profile
•   Up to 2 B lines per window are OK! Still = A profile
•   Z lines? Still = A profile
Test




       99
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C?
A, A’, B, B’ or C? (NB trick question)
A, A’, B, B’ or C? (NB trick question)
PLAPS: positive or negative?
PLAPS: positive or negative?
PLAPS: positive or negative?
PLAPS: positive or negative?
PLAPS: positive or negative?
PLAPS: positive or negative?
Normal lungs

•   A profile
•   Up to 2 B lines per window are OK
•   PLAPS negative
Pneumothorax

•   A’ profile = A lines (or no lines), sliding absent
•   There are no B lines at all on that side
•   There will be a lung point unless lung is completely
    collapsed
Acute cardiogenic pulmonary oedema
               (APO)
•    B profile =
    • lung rockets in all windows
    • lung sliding preserved
ARDS or pneumonia

B’   profile =
•     lung rockets in all windows
•     lung sliding reduced / absent
•     And pleural line may be irregular

A/B profile

C profile

A profile anteriorly, PLAPS positive
Pulmonary embolus

  
 A profile anteriorly, PLAPS positive or negative i.e.
lungs can look normal



   Sometimes C profile (pulmonary infarcts)
Asthma / COPD lungs look ‘normal’

•   A profile
•   PLAPS negative
Sticking needles in thorax




                       11
                        6
Chest drains/
          thoracocentesis
! Same rationale as central line placement
! Ensures you don’t stick ICC in the liver

! Tricks:
    ! Get patient to take maximal inspiration &
      expiration
    ! Scan in 2 planes

    ! Scan in same position you’ll insert ICC

    ! Use real time US




                                              11
                                               7
Let’s wrap this up




                     11
                      8
Lung US: top tips
!   Curved probe / FAST preset
!   At right angles to the ribs
!   Is there sliding? Tip: compare sides
!   A or B or C?
!   PLAPS or no PLAPS?




                                      11
                                       9
Any questions?

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3 lung and thorax

  • 1. Lung & thorax SAH & RNSH 2011 Critical Care Ultrasound Course Thanks to: Dr Paul Atkinson Dr Bishr Faheem Dr Daniel Lichtenstein
  • 2. Scanning the lung • Why scan the lung? • Probe & scanner settings • Technique • Landmarks • US findings • Terminology: the lung profiles • Matching the findings to the disease • Sticking needles & tubes in the lung 2
  • 3. Why scan the lung? • Diagnosis • Air in pleura: PTX • Fluid in pleura: blood, pus • Fluid in lung tissue: APO/ pneumonia / ARDS • Consolidated lung tissue: pneumonia / contusion / infarct (PE) / cancer • Procedures 3
  • 4. Why bother? • Lung US is more accurate than CXR for: • PTX (>95% versus 50%) • Pleural fluid (20ml versus 200ml) • APO sens 97%, spec 94%, acc 95% • PE?? Sens 74% … 81% if add DVT • It’s also • Faster (2 min versus 19 min) • Safer • Repeatable 4
  • 6. Patient position ! No need to sit patient up (eg trauma) ! In fact, accuracy for PTX is improved if lying flat… just harder to get round the back for pleural fluid ! Air rises ! Fluid sinks 6
  • 7. Probe ! Ideally the curved probe ! Linear array no anatomical info ! Phased array poor image quality 7
  • 8. Preset ! Abdo / FAST ! Not the commercial ‘lung’ settings ! Turn off filters ! Multibeam / compounding ! Tissue harmonics ! Why? You are looking for artefacts 8
  • 9. Depth ! Close up consolidation? = 5cm ! Just sliding / A / B lines? = 10cm ! Base of lung / diaphragm? = 15cm ! Making sure rockets are rockets? = 15cm 9
  • 10. Probe position ! Sagittal ! Right angles to the ribs ! Makes sure that the landmarks (rib shadows) stay in view 10
  • 11. Find those ribs ‘RIB’ ‘RIB’ 11
  • 12. Look between the ribs RIB RIB PLEURAL LINE (WHERE THE ACTION IS) 12
  • 13. So: ! Curved probe ! FAST / abdo preset ! 10-15cm depth ! Turn off fancy filters ! Sagittal / long axis of patient 13
  • 14. Where will I scan? Depends on clinical context 14
  • 15. The basic principle ! Air rises " scan highest point of the chest ! Fluid sinks " scan lowest point ! Some diseases are patchy (eg pneumonia, ARDS) " scan as much of the lung as possible (at least look at each lobe) 15
  • 16. Where will I scan? ! Cardiac arrest: highest point on each side ! Shock: 2 anterior (BLUE) points on each side ! Breathless: 3 points on each side ! Add 1 posterior (PLAPS) point ! Thorough look: as much of each lung as possible (improves accuracy) 16
  • 17. BLUE points & PLAPS points 17
  • 18. BLUE points & PLAPS points ! What the %$#% ??? ! Daniel Lichtenstein’s BLUE protocol ! BLUE is not an acronym ! PLAPS is, though 18
  • 19. BLUE points & PLAPS points ! Upper BLUE point = upper lobe ! Lower BLUE point = middle lobe / lingula ! PLAPS point = lower lobe 19
  • 26. PLAPS point ! ‘Postero- Lateral Alveolar / Pleural Syndrome’ ! What the %$#% ??? ! Posterolateral = round the back ! Alveolar syndrome = consolidation ! Pleural syndrome = pleural fluid 24
  • 27. PLAPS point ! The PLAPS point is the lowest point of the lung ! The Morison's Pouch of the thorax’ (thanks to Dr Chris Wong) ! So this is where you find pleural fluid ! If there’s no fluid here, there’s no fluid anywhere in the thorax! 25
  • 28. How to find the PLAPS point ! It’s the posterior continuation of the lower BLUE point (as far around as you can get the probe) 26
  • 29. How to find the PLAPS point 27
  • 30. How to find the PLAPS point 27
  • 31. Tip: watch out for the abdomen! ! If you scan the liver / spleen & think you’re still above the diaphragm, it will resemble consolidation ! ESP if you are using linear probe 28
  • 32. Tip: Get round as far back as you can! wrong right 29
  • 33. Tip: Get round as far back as you can! wrong right 29
  • 34. Tip: Get round as far back as you can! wrong right 29
  • 36. NB: ‘normal lung’ ! Pleural line looks like a ‘curtain’ sliding back & forth ! Sparkle = scatter from air in lung ! You don’t really seeing normal lung at all ! If it looks like liver: ! mirror ! hepatization 31
  • 37. What am I looking for? 32
  • 38. What am I looking for? ! Pleural fluid ! Pleural sliding ! A lines: reverb artefact from pleural line ! B lines: hyperechoic reverberation effect from air/water interface ! C: consolidation 33
  • 40. Pleural fluid ! Site: dependent regions ! Appearance: ! black = anechoic (fresh blood, transudate/ exudate) ! echogenic / stuff = blood, exudate ! Amount: as little as 20ml ! Sensitivity >97%, specificity 99-100% (Sisley et al, J Trauma 1998) 35
  • 44. Pleural fluid: caveats ! Pleural vs pericardial fluid (pericardial = delimited by descending aorta) ! Peritoneal fluid (where’s the diaphragm?) ! Small traces of fluid: easy to miss 38
  • 46. Duh! Just look all over the thorax
  • 47. A, B & Z lines 41
  • 48. A, B & Z lines ! A lines = horizontal & static = reverberation artefact from pleura ! B lines = vertical & move with resps (prev ‘comet tails’) = thick vertical lines which reach to edge of screen & obliterate A lines ! Z lines = vertical, fade quickly, don’t move with resps 42
  • 49. A lines 43
  • 50. A lines 44
  • 51. A lines Horizontal artefacts Only air is present Present in dry lungs Present in PTX 45
  • 52. B-line B line 46
  • 53. B lines Vertical artefacts Air/fluid mix in interlobular septa Equivalent of Kerley B lines Not seen in PTX Even 1 B line rules out PTX at that site 47
  • 54. B lines Vertical Bright Obliterate A lines Don’t fade! Reach all the way to the edge of the screen! 1 or 2 per lung field is OK 3 or more = ‘rockets’ 48
  • 55. Z-lines(Note: A line maintained) 49
  • 56. Z lines ! ill defined ! DON’T move with respiration ! DON’T erase the A lines 50
  • 57. Lung rockets ‘When several B lines are visible in a single scan, the pattern evokes a rocket at lift-off, and we have adopted the term ‘lung rockets’’ (Lichtenstein p106) 51
  • 58. Lung rockets 3 or more B lines per lung field = ‘rockets’ 52
  • 59. Not ‘comets’ International consensus dropped the term (terminology is confusing enough already) 53
  • 60. Rockets 54
  • 61. Rockets 54
  • 62. Top Tip Up to 1/3 normal patients have rockets in dependent regions So if you see rockets in PLAPS points, it doesn’t matter! 55
  • 63. Lung rockets = wet lungs ! Just in the bases = normal ! In all windows = cardiogenic oedema ! Patchy, with spared areas = non cardiogenic oedema / widespread pneumonia ! Localised = pneumonia / chronic interstitial diseases eg fibrosis 56
  • 64. Test Remember: 1 or 2 B lines are OK. Lung is still dry at that point! 57
  • 65. A, B or Z lines? Dry or wet? 58
  • 66. A, B or Z lines? Dry or wet? 59
  • 67. A, B or Z lines? Dry or wet? 60
  • 68. A, B or Z lines? Dry or wet? 61
  • 69. Applications of lung rockets ! Diagnosis ! Is it his CCF or COPD playing up today? ! Fluid status ! is this guy with a crap LV overloaded today? ! Guiding fluid resuscitation ! Fill him up until the rockets appear ! Dialyse him until the rockets disappear 62
  • 70. Validation ! Volpicelli et al, Am J Emerg Med 2006 (24): 689-696 ! N=300 (75 had AIS) ! Combined gold standard incl 1 month follow up ! sens spec ! Rockets 85.7% 97.7% 63
  • 71. Just remember ! Not all vertical lines are B lines ! Z lines = puny ! pseudo-rockets with subcut emphysema (don’t move with respiration, & can’t see normal rib shadow above them) ! Not all rockets = fluid ! widespread pneumonia ! widespread fibrosis ! rockets can be normal in lowest intercostal space ! Posterior lung rockets can be normal in supine patients 64
  • 73. Lung sliding ! Visceral pleura glides on parietal pleura ! Why is it important? ! A lines + sliding = dry lung = A profile ! A lines without sliding = PTX = A’ profile ! Rockets + sliding = APO = B profile ! Rockets without sliding = ARDS / pneumonia = B’ profile 66
  • 74. Lots of things can prevent lung sliding ! CAL ! Apices ! Failure to ventilate ! eg R main stem intubation (L lung doesn’t move) ! Eg pain (chest splinting) ! Pneumothorax ! Pneumonia & ARDS 67
  • 75. Lots of things can prevent lung sliding ! CAL ! Apices ! Failure to ventilate ! eg R main stem intubation (L lung doesn’t move) ! Eg pain (chest splinting) ! Pneumothorax ! Pneumonia & ARDS … ??? 68
  • 76. How the hell do pneumonia / ARDS reduce lung sliding? 69
  • 77. Here’s how: ARDS/ disseminated APO: pneumonia: Transudate Exudate Lung sliding is Proteinaceous preserved, smooth ‘sticky’ pleural line Reduced / absent lung B profile sliding, irregular pleural line B’ profile
  • 83. So how do I diagnose PTX? 74
  • 84. Diagnosis of PTX 1. No lung sliding 2. No B lines 3. Ideally, a lung point 75
  • 85. 1. a o lung sliding N 76
  • 86. Which side is the PTX?
  • 87. Which side is the PTX?
  • 88. Which side is the PTX?
  • 89. Tip 1: compare sides 78
  • 90. Tip 1: compare sides 78
  • 91. Tip 1: compare sides 78
  • 92. Tip 2: M-mode can help ! Sliding = seashore sign ! No sliding = stratosphere sign ! But beware ‘false seashore’ with chest wall movement! 79
  • 95. Stratosphere sign ! M-mode = motion mode ! If something isn’t moving, it’s a straight line 82
  • 96. 2. No B lines • i.e. the A’ profile (air is dry) • Even a single B line rules out PTX • Because B lines = air/fluid interface • Absent sliding + B line = LUNG • EG not ventilating • EG pneumonia 83
  • 97. 3. The lung point sign ! Specific to PTX ! the site where normal lung gives way to PTX ! on one side of the image sliding is present ! on the other side it is absent. 84
  • 99. What if there’s no lung point sign? there might still be a massive PTX which has collapsed the entire lung. Go back to the clinical picture & decide whether you need to go ahead & decompress the chest. 86
  • 100. Can I trust lung US for PTX? If you are just starting out: ! If you want to find all PTX: get a CT ! Stable patient, Negative CXR, positive EFAST: get a CT … or ask a friend to scan ! Unstable patient, Negative CXR, positive EFAST: decompress the chest ! Rushing to OT/ chopper, neg CXR, pos EFAST: warn anaesthetist or insert ICC 87
  • 101. Test 88
  • 107. Alveolar consolidation ! If you can see lung tissue, it ain’t normal! ! It ain’t aerated ! Collapse ! Consolidation ! Atelectasis ! Contusion ! Infarction (PE) 94
  • 109. Putting it all together 96
  • 110. Terminology • A profile = A lines (or no lines), sliding preserved • A’ profile = A lines (or no lines), sliding absent • B profile = lung rockets in all windows, sliding preserved • B’ profile = lung rockets in all windows, sliding reduced / absent • A/B profile = patchy rockets alternate with normal areas • C profile = areas of consolidation • PLAPS positive = consolidation / effusion at bases • PLAPS negative = anything else at bases (A lines / B lines / rockets)
  • 111. A word of advice about the A profile • All A lines = A profile • No lines seen? Still = A profile • Up to 2 B lines per window are OK! Still = A profile • Z lines? Still = A profile
  • 112. Test 99
  • 113. A, A’, B, B’ or C?
  • 114. A, A’, B, B’ or C?
  • 115. A, A’, B, B’ or C?
  • 116. A, A’, B, B’ or C?
  • 117. A, A’, B, B’ or C?
  • 118. A, A’, B, B’ or C?
  • 119. A, A’, B, B’ or C?
  • 120. A, A’, B, B’ or C?
  • 121. A, A’, B, B’ or C?
  • 122. A, A’, B, B’ or C?
  • 123. A, A’, B, B’ or C?
  • 124. A, A’, B, B’ or C?
  • 125. A, A’, B, B’ or C? (NB trick question)
  • 126. A, A’, B, B’ or C? (NB trick question)
  • 127. PLAPS: positive or negative?
  • 128. PLAPS: positive or negative?
  • 129. PLAPS: positive or negative?
  • 130. PLAPS: positive or negative?
  • 131. PLAPS: positive or negative?
  • 132. PLAPS: positive or negative?
  • 133. Normal lungs • A profile • Up to 2 B lines per window are OK • PLAPS negative
  • 134. Pneumothorax • A’ profile = A lines (or no lines), sliding absent • There are no B lines at all on that side • There will be a lung point unless lung is completely collapsed
  • 135. Acute cardiogenic pulmonary oedema (APO) • B profile = • lung rockets in all windows • lung sliding preserved
  • 136. ARDS or pneumonia B’ profile = • lung rockets in all windows • lung sliding reduced / absent • And pleural line may be irregular A/B profile C profile A profile anteriorly, PLAPS positive
  • 137. Pulmonary embolus A profile anteriorly, PLAPS positive or negative i.e. lungs can look normal Sometimes C profile (pulmonary infarcts)
  • 138. Asthma / COPD lungs look ‘normal’ • A profile • PLAPS negative
  • 139. Sticking needles in thorax 11 6
  • 140. Chest drains/ thoracocentesis ! Same rationale as central line placement ! Ensures you don’t stick ICC in the liver ! Tricks: ! Get patient to take maximal inspiration & expiration ! Scan in 2 planes ! Scan in same position you’ll insert ICC ! Use real time US 11 7
  • 141. Let’s wrap this up 11 8
  • 142. Lung US: top tips ! Curved probe / FAST preset ! At right angles to the ribs ! Is there sliding? Tip: compare sides ! A or B or C? ! PLAPS or no PLAPS? 11 9